Subsequent Oncology Visits Among Cancer Survivors Transitioned to Primary Care: A Retrospective Cohort Study

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Fishbein, Daryl Bainbridge, Som D. Mukherjee, Elizabeth Vadacchino, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9255005/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose: There is increasing focus on transitioning cancer survivors from oncology to primary care, yet little is known about why some patients return to oncology following transition. We aimed to describe the reasons for and outcomes of subsequent oncology visits among cancer survivors transitioned to primary care. Methods: We conducted a retrospective cohort study of patients transitioned to primary care at the Juravinski Cancer Centre. We analyzed all patients transitioned to primary care from 2013–2020. A chart review was completed for transitioned patients with subsequent oncology visits to determine the reasons for return and subsequent investigations/treatments. Results: Among 2,604 transitioned cancer survivors, 440 (16.9%) had a subsequent oncology visit. One-third were not true rereferrals but rather visits for genetic counselling, clinical trials, or palliative care follow-up (32.7%). Apart from these, the most common reasons for visit were investigation of symptoms (32.7%) or tests (23.2%). Recurrence or new disease was detected in 28.2% of those with a subsequent visit, representing 4.8% of all transitioned patients. Most of these patients went on to receive treatment. Conclusions: Only a small proportion of transitioned patients were referred back to oncology, and recurrence was detected in a small fraction of the overall cohort, supporting the safety of primary-care led survivorship. Patients were seen for many reasons and were readily able to reconnect with oncology regardless of underlying pathology. Implications for Cancer Survivors: Transitioning cancer survivors to primary care appears safe, with low recurrence rates and the ability to readily re-access oncology care when needed. Cancer survivorship primary care models of care transitions of care survivorship care models INTRODUCTION Cancer survivorship has improved dramatically over the past 50 years due to advances in screening, diagnosis and treatments. 1 In the United States alone, there are over 18 million cancer survivors, expected to increase to 26 million by 2040. 2 To address this growing population, there has been increased focus on transitioning cancer survivors to primary care providers for ongoing surveillance and follow-up. Several studies have shown this to be a cost-effective model with equivalent clinical and patient-reported outcomes compared with ongoing oncology follow-up. 3–6 Despite these benefits, little is known about why some patients subsequently return to oncology after transition. To the best of the authors’ knowledge, no study has identified why cancer survivors transitioned to primary care are subsequently referred back to oncology care after transition, or the outcomes of these referrals. Understanding these patterns is crucial to identify gaps in and help improve our current models of survivorship care. The aim of our study was to analyze the reasons cancer survivors transitioned to primary care return to oncology care, and to describe the care that they receive thereafter. We conducted a retrospective cohort study using data from Ontario, Canada to identify patients who were seen again in the cancer centre following transition to primary care. We described the reasons for their visits and the subsequent treatment they received, representing the first study to report this to date. Clarifying the reasons for and outcomes of rereferral is essential to ensure the safety of transition and to guide the development of risk-stratified survivorship care. METHODS Study Design We completed a retrospective cohort study of transitioned cancer patients utilizing the MOSAIQ Electronic Medical Record (EMR) at the Juravinski Cancer Centre (JCC) in Hamilton, Ontario, Canada. The primary objective of the study was to identify the reasons that transitioned patients returned to the cancer centre and to describe the oncology care that followed. The JCC is a large regional cancer centre serving approximately 23,000 patients annually. The EMR at the JCC has a system which, beginning in 2013, allows clinical staff to use a Transition Code (T-Code) to indicate when a patient is being transitioned to their primary care provider. A study database was created by the JCC Health Informatics Team for all cancer patients at the JCC with a T-Code current up to May 2020. Patient and clinical factors captured at the time of transition were linked in this database, including tumour disease type and stage at diagnosis, details of prior chemotherapy (defined as any systemic treatment given in the chemotherapy suite), radiation treatment, date of transition and dates of any oncology visits after transition. We previously reported on the creation of this patient cohort and the veracity of these data. 7 Ethical approval for this study was obtained from the Hamilton Integrated Research Ethics Board (#8090). Data Collection We considered patients in the transitioned cohort that had one or more documented visits to the JCC after their transition date to have had a subsequent visit and included them in the main analysis. The authors (FF, DB, EV, and RL) conducted a virtual chart review of the EMR documents of these patients dating from the last oncologist note(s) prior to the time of transition to December 2023 (minimum 3.8 years following initial transition). These analysts developed guidelines for the abstraction and a chart review spreadsheet containing the data elements to be extracted. The fields populated included: Transition note/description, Confirm transition (yes/no), Confirm first subsequent visit date (yes/no, correct date), Reason for subsequent visits, Test confirmed reoccurrence or secondary, Subsequent visit plan and action, and Subsequent visit outcome (e.g., no recurrence, prior metastatic disease treatment [Tx], recurrence Tx, new primary no Tx, etc.). The analysts independently abstracted the same ten random cases and then compared, discussed, and consolidated their findings. This process was completed again with ten different patients, at which point a high degree of consistency was reached and the remaining cases (patients) were divided among the four analysts for abstraction. The chart abstraction and revision of the chart review spreadsheet form was an iterative process, with the analysts meeting weekly to review the data extracted and adjust the form/guidelines. Any uncertainty in capturing data elements was reviewed by a minimum of two analysts and consensus met. The abstraction included a review of each patient’s transition care plan to affirm that the patient had been transitioned to their primary care provider. The completed spreadsheet data was checked by the lead authors (FF and DB) to spot inconsistencies in reporting and missing information, which were amended accordingly. Analysis Analysis of patient characteristics and chart abstraction data was descriptive. The lead authors (FF and DB) conducted a thematic analysis of the data under each field in the chart review spreadsheet that had been compiled. Main themes for each field were derived using a constant comparative approach. 8 Discrepancies in theme construction between the two analysts were compared and reconciled. Referral was made back to the original EMR documentation for clarification and validation. Consensus making among the researchers and an audit trail were maintained to help ensure methodological rigor of the analysis. 8 RESULTS Transitioned Cohort In total, 2,604 patients with a confirmed diagnosis of cancer were documented and confirmed as having their survivorship care transferred to primary care between September 2013 and February 2020. We previously reported in detail on the characteristics of this transitioned cohort. 8 Of this cohort, 440 (16.9%) had one or more subsequent visits to the cancer centre recorded after their transition date. The mean number of subsequent visits was 6.6 (median = 2, range 1 to 134). Table 1 presents the characteristics of the transitioned patients with and without subsequent visits. Demographic and clinical characteristics were similar between these groups, with a few exceptions. At transition, patients with a subsequent visit were more likely to have had prior chemotherapy and/or radiation treatment, be breast cancer survivors, and report at least moderate pain or wellbeing issues, compared to patients with no further oncology visits. Table 1 Demographic and clinical characteristics of patients transitioned to primary care with subsequent or no subsequent visits Characteristic Transitioned Group, n (%) N = 2604 Subsequent Visit Group, n (%) N = 440 Sex, Female 2,086 (80.1) 362 (82.3) Age, mean years (min – max) 65.9 (20–96) 64.2 (20–96) First Consult to Transition, mean days (min – max) 1,422.5 (0–13,030) 1,212.5 (0–10,876) Last Prior Chemo to Transition, mean days (min – max) 468.6 (0–2,429) 363.6 (0–2,372) Treatments prior to transition Prior Chemo 943 (36.2) 225 (51.1) Prior Radiation 850 (32.6) 163 (37.0) Prior Chemo and Radiation 476 (18.3) 114 (25.9) No Chemo or Radiation 1,284 (49.4) 166 (37.7) Clinical stage 0 142 (5.5) 26 (5.9) 1 1165 (44.7) 154 (35.0) 2 810 (31.1) 145 (33.0) 3 340 (13.1) 80 (18.2) 4 123 (4.7) 33 (7.5) Unstageable 14 (0.5) 2 (0.5) Not Cancer 10 (0.4) 0 Diagnosis at Transition Breast 1,217 (46.7) 253 (57.5) Endometrium 512 (19.7) 49 (11.1) Gastrointestinal—lower 209 (8.0) 54 (12.3) Prostate 169 (6.5) 12 (2.7) Melanoma and skin 118 (4.5) 14 (3.2) Hematological 102 (3.9) 10 (2.3) Genitourinary 68 (2.6) 9 (2.0) Gynecological 59 (2.3) 6 (1.4) Gastrointestinal—upper 49 (1.9) 17 (3.9) Sarcoma 44 (1.7) 6 (1.4) Head and neck 32 (1.2) 4 (0.9) Lung 16 (0.6) 4 (0.9) Central nervous system 3 (0.1) 0 Other or Unknown Malignant Neoplasm 6 (0.2) 2 (0.5) ESAS score 4 or greater* Pain 151 (12.7) 32 (16.7) Tiredness 317 (26.7) 51 (26.6) Drowsiness 143 (12.0) 23 (12.0) Nausea 25 (2.1) 5 (2.6) Lack of Appetite 108 (9.1) 24 (12.5) Shortness of Breath 114 (9.6) 19 (9.9) Depression 147 (12.4) 29 (15.1) Anxiety 217 (18.3) 35 (18.2) Wellbeing 280 (23.6) 55 (28.6) *The Edmonton Symptom Assessment System (ESAS) is a widely used and validated tool to screen for self reporting the severity of 9 symptoms on a scale of 0–10 (10 = worst): anxiety, appetite, depression, drowsiness, nausea, pain, shortness of breath, tiredness, and well-being. Scores four or above are considered moderate for a given symptom. ESAS data is missing for about 54% of patients, who did not complete this measure within three months prior to transition date. Reasons for Subsequent Visit(s) Table 2 presents the reasons for subsequent visits among patients transitioned to primary care. The most common reason for a subsequent visit was for investigations of tests or symptoms where 144 patients (32.7%) were seen for oncologist investigation of test(s) the patient had done and/or confirmed pathology, and 102 patients (23.2%) were seen for oncologist investigation of symptoms (including pain, fatigue, bleeding, etc.), prior to any tests being done. Twenty-nine patients (6.6%) had metastatic disease at the time of transition, and were subsequently referred back for ongoing oncologic care. Sixteen patients (3.6%) were seen at their request for discussion, examination and/or resources, but without any symptoms or prior tests. One hundred and forty-four patients (32.7%) were not true rereferrals, but rather seen for genetic testing only (15.2%), clinical trial monitoring only (2.5%), palliative care or surgeon follow-up only (3.0% each), or genetic counselling with gynecologist monitoring (0.7%). Similarly, 13 patients (3.0%) only had a single subsequent visit, likely due to a pre-existing appointment made at the time of transition, and 24 patients (5.5%) did not actually have a physical visit, but rather only a phone discussion or note from another provider. Table 2 Reason for Subsequent Visit Among Patients Transitioned to Primary Care, N = 440 Reason for subsequent visits (mutually exclusive) Total number of patients % No subsequent physical visit (phone discussion or note from other provider) 24 5.5% Patient transitioned to primary care after single follow-up with other oncologist with no further visits (likely had appointment booked with other oncologist at time of transition) 13 3.0% Genetic counselling only* 67 15.2% Genetic counselling followed by gynecologist visits for monitoring, no recurrence or Tx 3 0.7% Clinical trial monitoring only** 11 2.5% Hormone therapy adjustment only 5 1.1% Patient requested oncologist follow-up for discussion, examination, or resources (no recurrence or Tx) 16 3.6% Supportive (palliative) Care Team only 13 3.0% Surgeon follow-up only 13 3.0% Oncologist investigation of symptoms 102 23.2% Oncologist investigation of test(s) 144 32.7% Prior metastatic disease oncology follow-up (metastatic disease at transition) 29 6.6% *3 patients also saw the Supportive (palliative) Care Team at the JCC **1 patient also had Genetic counselling visit Table 3 Outcome and Treatment of Investigation or Metastatic Disease Follow-up, N = 275 Outcome of Investigation of symptoms and/or tests Total number of patients % No recurrence detected 122 44.4% Recurrence confirmed 59 21.5% New primary confirmed 20 7.3% Metastatic disease confirmed post-transition 45 16.4% Prior metastatic disease follow-up with subsequent treatment 19 6.9% Prior metastatic disease follow-up with no subsequent treatment 10 3.6% Cancer Treatment* for Recurrent, New Primary, or Metastatic Cancer (N = 143**) No cancer treatment† 13 9.1% Chemotherapy only 43 30.1% Radiation therapy only 29 20.3% Chemotherapy and radiation therapy 19 13.3% Surgery only 11 7.7% Hormone therapy only (including modification to existing regime) 12 8.4% Chemotherapy and radiation therapy and surgery 6 4.2% Surgery and either chemotherapy or radiation therapy 7 4.9% Hormone therapy and other (surgery or chemotherapy) 3 2.1% * Cancer treatment refers to chemotherapy, radiation therapy, surgery, and/or hormone therapy ** Incudes all patients 1) seen for Investigation of symptoms or tests or 2) those with prior metastatic disease (at t-code) with treatment planned. 6 of these patients were also seen for genetic counselling at subsequent visits, in addition to treatment † includes 6 patients with metastatic disease confirmed post-transition and 3 patients who only saw the Supportive (palliative) Care Team at the JCC Subsequent investigation and treatment Among transitioned patients with a subsequent visit, 275 patients (62.5%) went on to have further investigations, either for symptoms or results from previous tests, or follow-up of known prior metastatic disease. Table 3 summarizes the outcome of these investigations. Just under half of these patients (124) had new cancer detected, with 59 patients (21.5%) having a recurrence confirmed, 45 (16.4%) having new metastatic disease confirmed, and 20 (7.3%) having a new primary confirmed. Of patients with recurrent, new primary, or metastatic cancer, 130 went on to receive treatment (90.1%). Forty-three (30.1%) received chemotherapy only, 29 (20.3%) received radiation only, and 19 (13.3%) received chemotherapy and radiation therapy. The remainder received surgery only (7.7%), hormone therapy only (8.4%), chemotherapy and radiation and surgery (4.2%), surgery and chemotherapy or radiation therapy (4.9%), or hormone therapy and surgery or chemotherapy (2.1%). DISCUSSION This retrospective cohort study provides new insights into why cancer patients formally transitioned from oncology to primary care are seen again at the cancer centre. Our study identified 440 patients out of 2,604 patients with care transitioned with a subsequent oncology visit. Many were not true “re-referrals”, but rather appointments for genetic counselling, clinical trial monitoring, palliative care treatment, etc. Excluding these patients, we found that only a small proportion of patients (11.4%) among those transitioned were re-referred for further oncologic assessment following transition to primary care. This is reassuring, as transition is intended for patients who no longer need routine oncology assessment, and overall supports the appropriateness of transitioning eligible survivors to primary care. We found diverse reasons for subsequent visits, which the most common being for investigations of tests or symptoms, or for patient requested follow-up (without symptoms or preexisting tests). Over 40% of subsequent visit cases were not related to cancer investigation, implying that, at least at the study centre, patients can reconnect with the cancer care system after transition regardless of pathology. This is encouraging as one of cancer patients’ main reluctances to transitioning to primary care is fear of losing direct access to their oncology providers. 9 Of transitioned patients with a subsequent visit, 124 (28.2%) were found to have recurrent disease, new metastatic disease or a new primary, and most patients with underlying disease went on to receive cancer treatment (90.1%). Overall, this is a small fraction of the total transitioned patients (4.8%), in line with recurrence rates for early stage common malignancies. 10 – 12 This is reassuring, underscoring that patients transitioned to primary care experience low recurrence rates overall, supporting the safety of this approach. However, it is a comparatively larger fraction of the patients seen for a subsequent visit (28.2%), highlighting that these referrals can be clinically significant, supporting the need for careful risk stratification at the time of transition, as well as clear guidelines for when to re-refer to specialist care. The body of empirical literature reporting on the transition of patients from oncology to primary care is limited, in part due to most cancer systems not formally tracking this transfer of care. 7 Some studies have described patterns of follow-up care amongst cancer survivors, including whether this is oncology-led or primary-care led, as well as the frequency of visits, with stratifications by cancer site and stage. Previous Canadian studies have shown a wide variation in follow-up care: many oncologists are discharging their patients to primary care-based follow-up, however there is still a substantial number of patients that see both oncologists and primary care providers in the survivorship phase. 13 , 14 Similar variation has been reported in U.S. studies as well. 14 , 15 Despite this variation, numerous studies have shown that cancer survivors transitioned to primary care have equivalent outcomes in recurrence, survival, and quality of life when compared to ongoing oncology follow-up, leading to a growing movement to transition appropriate survivors to primary care. 4–6,16 To our knowledge, no study to date has specifically investigated the clinical outcomes of transitioned patients referred back to oncologic care, and the reasons for these referrals. Our findings address an important gap in survivorship literature, with implications for guiding future models of risk-stratified follow-up. There are several limitations to our study. Firstly, there are transitioned patients who may have received subsequent oncology care outside of the study region and therefore would not have been captured in our cohort. This is likely only a small number of patients, as our EMR includes data from other cancer centres in the region, but not outside the province or country. Secondly, certain subsequent visits were not true “re-referrals” but rather appointments for genetic counselling, clinical trial monitoring, etc., which we account for in our discussion and analysis. Thirdly, our study looked at patients transitioned between 2013–2020. Since this time, patterns of care relating to transitioning patients to primary care and length of follow-up by oncology may have changed. In addition, this period marked the beginning of growing strain on the primary care system in Canada, with increasing family physician shortages throughout Canada. Finally, we cannot speak to the generalizability of our findings to other cancer centres and health care systems. Strengths of our study include the large sample size drawn from a cancer centre serving approximately 23,000 patients annually. Transition to primary care in our study cohort was formally documented in the EMR, whereas other studies have had to assume patient transition based on patients not having oncology visits in the year(s) following completion of treatment. 17 We carried out a rigorous chart review capturing detailed clinical variables and affirming patterns of care. Finally, we had a longer follow-up period with a minimum of 3.8 years from initial transition allowing sufficient time to observe clinically meaningful outcomes. Future directions include larger scale analyses of patient, disease, and treatment factors that predict the need for longer term follow-up to help inform safe transitions to primary care. Our work also shows that cancer survivors are able to readily access the cancer centre again post-transition, and further research examining how patients re-enter the oncology system (including referral mechanism, timelines, and any potential barriers to accessing care) would be useful. Finally, further studies addressing healthcare utilization and costs associated with re-referrals, as well as the development of more robust guidelines for primary care providers on when to re-refer to specialist care, are warranted. In conclusion, we have provided one of the first analyses of why cancer survivors transitioned to primary care subsequently return to oncologic care. We found that only a small proportion of transitioned patients are referred back for oncologic assessment, most often for investigation of symptoms or tests. Patients were readily able to connect with the cancer centre regardless of underlying pathology. Just over a quarter of patients had a recurrence or a new primary, and most patients with identified cancer went on to receive treatment. Overall, this represents a small fraction of the transitioned cohort, affirming the safety of transition while underscoring the need for risk-stratified survivorship pathways and clear re-referral guidelines for primary care providers. Declarations Competing Interests: The authors declare no conflict of interest. Ethics Approval: The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the Hamilton Integrated Research Ethics Board (protocol code 8090; approved on Nov-18-2019). Disclaimers None. Funding: This research was funded by the Hamilton Health Sciences Foundation. Author Contribution Study conception and design were led by Jonathan Sussman, Som D. Mukherjee, Daryl Bainbridge, and Francine S. Fishbein. Material preparation, data collection, and analysis were performed by Francine S. Fishbein, Daryl Bainbridge, Elizabeth Vadacchino, and Russell Leong. The first draft of the manuscript was written by Francine S. Fishbein, and all authors commented on previous versions of the manuscript. Jonathan Sussman, Som D. Mukherjee, and Daryl Bainbridge provided senior supervision. All authors read and approved the final manuscript. References Parry C, Kent EE, Mariotto AB, et al. Cancer survivors: a booming population. Cancer Epidemiol Biomarkers Prev. 2011;20:1996–2005. Tonorezos E, Devasia T, Mariotto AB, et al. Prevalence of cancer survivors in the United States. JNCI: J Natl Cancer Inst. 2024;116:1784–90. Vos JAM, Wieldraaijer T, van Weert H, et al. Survivorship care for cancer patients in primary versus secondary care: a systematic review. J Cancer Surviv. 2021;15:66–76. Høeg BL, Bidstrup PE, Karlsen RV, et al. Follow-up strategies following completion of primary cancer treatment in adult cancer survivors. Cochrane Database of Systematic Reviews; 2019. Emery JD, Jefford M, King M, et al. ProCare Trial: a phase II randomized controlled trial of shared care for follow-up of men with prostate cancer. BJU Int. 2017;119:381–9. Grunfeld E, Levine MN, Julian JA, et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2006;24:848–55. Mukherjee SD, Bainbridge D, Hillis C, et al. Optimizing Cancer Survivorship Care: Examination of Factors Associated with Transition to Primary Care. Curr Oncol. 2023;30:2743–50. Creswell JW, Poth CN. Qualitative inquiry and research design: Choosing among five approaches. Sage; 2016. Liemburg GB, Korevaar JC, Logtenberg M, et al. Cancer follow-up in primary care after treatment with curative intent: Views of patients with breast and colorectal cancer. Patient Educ Couns. 2024;122:108139. Stemmer SM, Steiner M, Rizel S, et al. Ten-year clinical outcomes in N0 ER+ breast cancer patients with Recurrence Score-guided therapy. NPJ Breast Cancer. 2019;5:41. Nors J, Iversen LH, Erichsen R, et al. Incidence of Recurrence and Time to Recurrence in Stage I to III Colorectal Cancer: A Nationwide Danish Cohort Study. JAMA Oncol. 2024;10:54–62. Rajaram R, Huang Q, Li RZ, et al. Recurrence-Free Survival in Patients With Surgically Resected Non-Small Cell Lung Cancer: A Systematic Literature Review and Meta-Analysis. Chest. 2024;165:1260–70. Urquhart R, Lethbridge L, Porter GA. Patterns of cancer centre follow-up care for survivors of breast, colorectal, gynecologic, and prostate cancer. Curr Oncol. 2017;24:360–6. Kendell C, Decker KM, Groome PA, et al. Use of physician services during the survivorship phase: a multi-province study of women diagnosed with breast cancer. Curr Oncol. 2017;24:81–9. Parmeshwar R, Margenthaler JA, Allam E, et al. Patient surveillance after initial breast cancer therapy: variation by physician specialty. Am J Surg. 2013;206:218–22. Lewis RA, Neal RD, Williams NH, et al. Follow-up of cancer in primary care versus secondary care: systematic review. Br J Gen Pract. 2009;59:e234–47. Sussman J, Cerasuolo JO, Pond GR, et al. Patterns of Survivorship Follow-Up Care Among Patients With Breast Cancer: A Retrospective Population-Based Cohort Study in Ontario, Canada, Between 2006 and 2016. JCO Oncol Pract. 2025;21:188–98. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 06 Apr, 2026 Reviewers invited by journal 04 Apr, 2026 Editor assigned by journal 30 Mar, 2026 Submission checks completed at journal 30 Mar, 2026 First submitted to journal 28 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9255005","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618501239,"identity":"0293fd95-41ae-4508-9254-7042afeb3afd","order_by":0,"name":"Francine S. 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Mukherjee","email":"","orcid":"","institution":"McMaster University","correspondingAuthor":false,"prefix":"","firstName":"Som","middleName":"D.","lastName":"Mukherjee","suffix":""},{"id":618501242,"identity":"061ad53c-ec7a-4c33-9a93-69a321d38fd1","order_by":3,"name":"Elizabeth Vadacchino","email":"","orcid":"","institution":"McMaster University","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Vadacchino","suffix":""},{"id":618501246,"identity":"96bbb25d-71e8-4a55-a703-6eee7bc25034","order_by":4,"name":"Russell Leong","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"prefix":"","firstName":"Russell","middleName":"","lastName":"Leong","suffix":""},{"id":618501251,"identity":"8298be26-2a35-4280-bc9d-e980804ad73b","order_by":5,"name":"Jonathan Sussman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArElEQVRIiWNgGAWjYBADOQMJUrUYk64lcQPRWuRnpD/+dKPmTvp26faHHxhq7AhrMbiRYyadc+xZ7s45Z4wlGI4lE6FFIoeNOYftcO6GGzlsDIwNzMQ57HPOv8PpBjfSnwG11BPWwnAjwUA6t+1wgsGNBDOglsNEOOzMGzPp3L7DhkCHGUskHDtOhMPaQQ77dlge6LCHHz7UVBPhMBSQQKqGUTAKRsEoGAXYAQABNzqPJndDlAAAAABJRU5ErkJggg==","orcid":"","institution":"McMaster University","correspondingAuthor":true,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Sussman","suffix":""}],"badges":[],"createdAt":"2026-03-28 19:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9255005/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9255005/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106769955,"identity":"d611461e-1a37-4f00-a7fe-7649a7fafc4a","added_by":"auto","created_at":"2026-04-13 09:58:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":807913,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9255005/v1/9e315bfb-1de2-49f9-b9e5-0fa3ab5f7eb5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Subsequent Oncology Visits Among Cancer Survivors Transitioned to Primary Care: A Retrospective Cohort Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCancer survivorship has improved dramatically over the past 50 years due to advances in screening, diagnosis and treatments.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In the United States alone, there are over 18\u0026nbsp;million cancer survivors, expected to increase to 26\u0026nbsp;million by 2040.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e To address this growing population, there has been increased focus on transitioning cancer survivors to primary care providers for ongoing surveillance and follow-up. Several studies have shown this to be a cost-effective model with equivalent clinical and patient-reported outcomes compared with ongoing oncology follow-up. \u003csup\u003e3\u0026ndash;6\u003c/sup\u003e Despite these benefits, little is known about why some patients subsequently return to oncology after transition. To the best of the authors\u0026rsquo; knowledge, no study has identified why cancer survivors transitioned to primary care are subsequently referred back to oncology care after transition, or the outcomes of these referrals. Understanding these patterns is crucial to identify gaps in and help improve our current models of survivorship care.\u003c/p\u003e \u003cp\u003eThe aim of our study was to analyze the reasons cancer survivors transitioned to primary care return to oncology care, and to describe the care that they receive thereafter. We conducted a retrospective cohort study using data from Ontario, Canada to identify patients who were seen again in the cancer centre following transition to primary care. We described the reasons for their visits and the subsequent treatment they received, representing the first study to report this to date. Clarifying the reasons for and outcomes of rereferral is essential to ensure the safety of transition and to guide the development of risk-stratified survivorship care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eWe completed a retrospective cohort study of transitioned cancer patients utilizing the MOSAIQ Electronic Medical Record (EMR) at the Juravinski Cancer Centre (JCC) in Hamilton, Ontario, Canada. The primary objective of the study was to identify the reasons that transitioned patients returned to the cancer centre and to describe the oncology care that followed. The JCC is a large regional cancer centre serving approximately 23,000 patients annually. The EMR at the JCC has a system which, beginning in 2013, allows clinical staff to use a Transition Code (T-Code) to indicate when a patient is being transitioned to their primary care provider. A study database was created by the JCC Health Informatics Team for all cancer patients at the JCC with a T-Code current up to May 2020. Patient and clinical factors captured at the time of transition were linked in this database, including tumour disease type and stage at diagnosis, details of prior chemotherapy (defined as any systemic treatment given in the chemotherapy suite), radiation treatment, date of transition and dates of any oncology visits after transition. We previously reported on the creation of this patient cohort and the veracity of these data.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Ethical approval for this study was obtained from the Hamilton Integrated Research Ethics Board (#8090).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eWe considered patients in the transitioned cohort that had one or more documented visits to the JCC after their transition date to have had a subsequent visit and included them in the main analysis. The authors (FF, DB, EV, and RL) conducted a virtual chart review of the EMR documents of these patients dating from the last oncologist note(s) prior to the time of transition to December 2023 (minimum 3.8 years following initial transition). These analysts developed guidelines for the abstraction and a chart review spreadsheet containing the data elements to be extracted. The fields populated included: Transition note/description, Confirm transition (yes/no), Confirm first subsequent visit date (yes/no, correct date), Reason for subsequent visits, Test confirmed reoccurrence or secondary, Subsequent visit plan and action, and Subsequent visit outcome (e.g., no recurrence, prior metastatic disease treatment [Tx], recurrence Tx, new primary no Tx, etc.). The analysts independently abstracted the same ten random cases and then compared, discussed, and consolidated their findings. This process was completed again with ten different patients, at which point a high degree of consistency was reached and the remaining cases (patients) were divided among the four analysts for abstraction. The chart abstraction and revision of the chart review spreadsheet form was an iterative process, with the analysts meeting weekly to review the data extracted and adjust the form/guidelines. Any uncertainty in capturing data elements was reviewed by a minimum of two analysts and consensus met. The abstraction included a review of each patient\u0026rsquo;s transition care plan to affirm that the patient had been transitioned to their primary care provider. The completed spreadsheet data was checked by the lead authors (FF and DB) to spot inconsistencies in reporting and missing information, which were amended accordingly.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eAnalysis of patient characteristics and chart abstraction data was descriptive. The lead authors (FF and DB) conducted a thematic analysis of the data under each field in the chart review spreadsheet that had been compiled. Main themes for each field were derived using a constant comparative approach.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Discrepancies in theme construction between the two analysts were compared and reconciled. Referral was made back to the original EMR documentation for clarification and validation. Consensus making among the researchers and an audit trail were maintained to help ensure methodological rigor of the analysis.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eTransitioned Cohort\u003c/h2\u003e \u003cp\u003eIn total, 2,604 patients with a confirmed diagnosis of cancer were documented and confirmed as having their survivorship care transferred to primary care between September 2013 and February 2020. We previously reported in detail on the characteristics of this transitioned cohort.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Of this cohort, 440 (16.9%) had one or more subsequent visits to the cancer centre recorded after their transition date. The mean number of subsequent visits was 6.6 (median\u0026thinsp;=\u0026thinsp;2, range 1 to 134). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the characteristics of the transitioned patients with and without subsequent visits. Demographic and clinical characteristics were similar between these groups, with a few exceptions. At transition, patients with a subsequent visit were more likely to have had prior chemotherapy and/or radiation treatment, be breast cancer survivors, and report at least moderate pain or wellbeing issues, compared to patients with no further oncology visits.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of patients transitioned to primary care with subsequent or no subsequent visits\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransitioned Group, n (%)\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2604\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubsequent Visit Group, n (%)\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;440\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex, Female\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2,086 (80.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e362 (82.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, mean years (min \u0026ndash; max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65.9 (20\u0026ndash;96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.2 (20\u0026ndash;96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFirst Consult to Transition, mean days (min \u0026ndash; max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1,422.5 (0\u0026ndash;13,030)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,212.5 (0\u0026ndash;10,876)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLast Prior Chemo to Transition, mean days (min \u0026ndash; max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e468.6 (0\u0026ndash;2,429)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e363.6 (0\u0026ndash;2,372)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatments prior to transition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior Chemo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e943 (36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e225 (51.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior Radiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e850 (32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e163 (37.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior Chemo and Radiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e476 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114 (25.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Chemo or Radiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1,284 (49.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e166 (37.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e142 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1165 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154 (35.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e810 (31.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e145 (33.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e340 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (18.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnstageable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis at Transition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1,217 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e253 (57.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e512 (19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal\u0026mdash;lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e209 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (12.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e169 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMelanoma and skin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e118 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenitourinary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGynecological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal\u0026mdash;upper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead and neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral nervous system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther or Unknown Malignant Neoplasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eESAS score 4 or greater*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e151 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiredness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e317 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (26.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrowsiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e143 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (12.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of Appetite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShortness of Breath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e147 (12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (15.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e217 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (18.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e280 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*The Edmonton Symptom Assessment System (ESAS) is a widely used and validated tool to screen for self reporting the severity of 9 symptoms on a scale of 0\u0026ndash;10 (10\u0026thinsp;=\u0026thinsp;worst): anxiety, appetite, depression, drowsiness, nausea, pain, shortness of breath, tiredness, and well-being. Scores four or above are considered moderate for a given symptom. ESAS data is missing for about 54% of patients, who did not complete this measure within three months prior to transition date.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReasons for Subsequent Visit(s)\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the reasons for subsequent visits among patients transitioned to primary care. The most common reason for a subsequent visit was for investigations of tests or symptoms where 144 patients (32.7%) were seen for oncologist investigation of test(s) the patient had done and/or confirmed pathology, and 102 patients (23.2%) were seen for oncologist investigation of symptoms (including pain, fatigue, bleeding, etc.), prior to any tests being done. Twenty-nine patients (6.6%) had metastatic disease at the time of transition, and were subsequently referred back for ongoing oncologic care. Sixteen patients (3.6%) were seen at their request for discussion, examination and/or resources, but without any symptoms or prior tests.\u003c/p\u003e \u003cp\u003eOne hundred and forty-four patients (32.7%) were not true rereferrals, but rather seen for genetic testing only (15.2%), clinical trial monitoring only (2.5%), palliative care or surgeon follow-up only (3.0% each), or genetic counselling with gynecologist monitoring (0.7%). Similarly, 13 patients (3.0%) only had a single subsequent visit, likely due to a pre-existing appointment made at the time of transition, and 24 patients (5.5%) did not actually have a physical visit, but rather only a phone discussion or note from another provider.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReason for Subsequent Visit Among Patients Transitioned to Primary Care, N\u0026thinsp;=\u0026thinsp;440\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason for subsequent visits (mutually exclusive)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal number of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo subsequent physical visit (phone discussion or note from other provider)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient transitioned to primary care after single follow-up with other oncologist with no further visits (likely had appointment booked with other oncologist at time of transition)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenetic counselling only*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenetic counselling followed by gynecologist visits for monitoring, no recurrence or Tx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical trial monitoring only**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHormone therapy adjustment only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient requested oncologist follow-up for discussion, examination, or resources (no recurrence or Tx)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupportive (palliative) Care Team only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgeon follow-up only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOncologist investigation of symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOncologist investigation of test(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior metastatic disease oncology follow-up (metastatic disease at transition)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*3 patients also saw the Supportive (palliative) Care Team at the JCC\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e**1 patient also had Genetic counselling visit\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcome and Treatment of Investigation or Metastatic Disease Follow-up, N\u0026thinsp;=\u0026thinsp;275\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOutcome of Investigation of symptoms and/or tests\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal number of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo recurrence detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence confirmed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew primary confirmed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetastatic disease confirmed post-transition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior metastatic disease follow-up with subsequent treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior metastatic disease follow-up with no subsequent treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCancer Treatment* for Recurrent, New Primary, or Metastatic Cancer (N\u0026thinsp;=\u0026thinsp;143**)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo cancer treatment\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation therapy only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy and radiation therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHormone therapy only (including modification to existing regime)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy and radiation therapy and surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery and either chemotherapy or radiation therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHormone therapy and other (surgery or chemotherapy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Cancer treatment refers to chemotherapy, radiation therapy, surgery, and/or hormone therapy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e** Incudes all patients 1) seen for Investigation of symptoms or tests or 2) those with prior metastatic disease (at t-code) with treatment planned. 6 of these patients were also seen for genetic counselling at subsequent visits, in addition to treatment\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026dagger; includes 6 patients with metastatic disease confirmed post-transition and 3 patients who only saw the Supportive (palliative) Care Team at the JCC\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSubsequent investigation and treatment\u003c/h3\u003e\n\u003cp\u003eAmong transitioned patients with a subsequent visit, 275 patients (62.5%) went on to have further investigations, either for symptoms or results from previous tests, or follow-up of known prior metastatic disease. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the outcome of these investigations. Just under half of these patients (124) had new cancer detected, with 59 patients (21.5%) having a recurrence confirmed, 45 (16.4%) having new metastatic disease confirmed, and 20 (7.3%) having a new primary confirmed.\u003c/p\u003e \u003cp\u003eOf patients with recurrent, new primary, or metastatic cancer, 130 went on to receive treatment (90.1%). Forty-three (30.1%) received chemotherapy only, 29 (20.3%) received radiation only, and 19 (13.3%) received chemotherapy and radiation therapy. The remainder received surgery only (7.7%), hormone therapy only (8.4%), chemotherapy and radiation and surgery (4.2%), surgery and chemotherapy or radiation therapy (4.9%), or hormone therapy and surgery or chemotherapy (2.1%).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis retrospective cohort study provides new insights into why cancer patients formally transitioned from oncology to primary care are seen again at the cancer centre. Our study identified 440 patients out of 2,604 patients with care transitioned with a subsequent oncology visit. Many were not true \u0026ldquo;re-referrals\u0026rdquo;, but rather appointments for genetic counselling, clinical trial monitoring, palliative care treatment, etc. Excluding these patients, we found that only a small proportion of patients (11.4%) among those transitioned were re-referred for further oncologic assessment following transition to primary care. This is reassuring, as transition is intended for patients who no longer need routine oncology assessment, and overall supports the appropriateness of transitioning eligible survivors to primary care. We found diverse reasons for subsequent visits, which the most common being for investigations of tests or symptoms, or for patient requested follow-up (without symptoms or preexisting tests). Over 40% of subsequent visit cases were not related to cancer investigation, implying that, at least at the study centre, patients can reconnect with the cancer care system after transition regardless of pathology. This is encouraging as one of cancer patients\u0026rsquo; main reluctances to transitioning to primary care is fear of losing direct access to their oncology providers.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Of transitioned patients with a subsequent visit, 124 (28.2%) were found to have recurrent disease, new metastatic disease or a new primary, and most patients with underlying disease went on to receive cancer treatment (90.1%). Overall, this is a small fraction of the total transitioned patients (4.8%), in line with recurrence rates for early stage common malignancies.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e This is reassuring, underscoring that patients transitioned to primary care experience low recurrence rates overall, supporting the safety of this approach. However, it is a comparatively larger fraction of the patients seen for a subsequent visit (28.2%), highlighting that these referrals can be clinically significant, supporting the need for careful risk stratification at the time of transition, as well as clear guidelines for when to re-refer to specialist care.\u003c/p\u003e \u003cp\u003eThe body of empirical literature reporting on the transition of patients from oncology to primary care is limited, in part due to most cancer systems not formally tracking this transfer of care.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Some studies have described patterns of follow-up care amongst cancer survivors, including whether this is oncology-led or primary-care led, as well as the frequency of visits, with stratifications by cancer site and stage. Previous Canadian studies have shown a wide variation in follow-up care: many oncologists are discharging their patients to primary care-based follow-up, however there is still a substantial number of patients that see both oncologists and primary care providers in the survivorship phase.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Similar variation has been reported in U.S. studies as well.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Despite this variation, numerous studies have shown that cancer survivors transitioned to primary care have equivalent outcomes in recurrence, survival, and quality of life when compared to ongoing oncology follow-up, leading to a growing movement to transition appropriate survivors to primary care. \u003csup\u003e4\u0026ndash;6,16\u003c/sup\u003e To our knowledge, no study to date has specifically investigated the clinical outcomes of transitioned patients referred back to oncologic care, and the reasons for these referrals. Our findings address an important gap in survivorship literature, with implications for guiding future models of risk-stratified follow-up.\u003c/p\u003e \u003cp\u003eThere are several limitations to our study. Firstly, there are transitioned patients who may have received subsequent oncology care outside of the study region and therefore would not have been captured in our cohort. This is likely only a small number of patients, as our EMR includes data from other cancer centres in the region, but not outside the province or country. Secondly, certain subsequent visits were not true \u0026ldquo;re-referrals\u0026rdquo; but rather appointments for genetic counselling, clinical trial monitoring, etc., which we account for in our discussion and analysis. Thirdly, our study looked at patients transitioned between 2013\u0026ndash;2020. Since this time, patterns of care relating to transitioning patients to primary care and length of follow-up by oncology may have changed. In addition, this period marked the beginning of growing strain on the primary care system in Canada, with increasing family physician shortages throughout Canada. Finally, we cannot speak to the generalizability of our findings to other cancer centres and health care systems.\u003c/p\u003e \u003cp\u003eStrengths of our study include the large sample size drawn from a cancer centre serving approximately 23,000 patients annually. Transition to primary care in our study cohort was formally documented in the EMR, whereas other studies have had to assume patient transition based on patients not having oncology visits in the year(s) following completion of treatment.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e We carried out a rigorous chart review capturing detailed clinical variables and affirming patterns of care. Finally, we had a longer follow-up period with a minimum of 3.8 years from initial transition allowing sufficient time to observe clinically meaningful outcomes. Future directions include larger scale analyses of patient, disease, and treatment factors that predict the need for longer term follow-up to help inform safe transitions to primary care. Our work also shows that cancer survivors are able to readily access the cancer centre again post-transition, and further research examining how patients re-enter the oncology system (including referral mechanism, timelines, and any potential barriers to accessing care) would be useful. Finally, further studies addressing healthcare utilization and costs associated with re-referrals, as well as the development of more robust guidelines for primary care providers on when to re-refer to specialist care, are warranted.\u003c/p\u003e \u003cp\u003eIn conclusion, we have provided one of the first analyses of why cancer survivors transitioned to primary care subsequently return to oncologic care. We found that only a small proportion of transitioned patients are referred back for oncologic assessment, most often for investigation of symptoms or tests. Patients were readily able to connect with the cancer centre regardless of underlying pathology. Just over a quarter of patients had a recurrence or a new primary, and most patients with identified cancer went on to receive treatment. Overall, this represents a small fraction of the transitioned cohort, affirming the safety of transition while underscoring the need for risk-stratified survivorship pathways and clear re-referral guidelines for primary care providers.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting Interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics Approval:\u003c/h2\u003e \u003cp\u003e The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the Hamilton Integrated Research Ethics Board (protocol code 8090; approved on Nov-18-2019).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDisclaimers\u003c/strong\u003e \u003cp\u003eNone.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research was funded by the Hamilton Health Sciences Foundation.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy conception and design were led by Jonathan Sussman, Som D. Mukherjee, Daryl Bainbridge, and Francine S. Fishbein. Material preparation, data collection, and analysis were performed by Francine S. Fishbein, Daryl Bainbridge, Elizabeth Vadacchino, and Russell Leong. The first draft of the manuscript was written by Francine S. Fishbein, and all authors commented on previous versions of the manuscript. Jonathan Sussman, Som D. Mukherjee, and Daryl Bainbridge provided senior supervision. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eParry C, Kent EE, Mariotto AB, et al. Cancer survivors: a booming population. Cancer Epidemiol Biomarkers Prev. 2011;20:1996\u0026ndash;2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTonorezos E, Devasia T, Mariotto AB, et al. Prevalence of cancer survivors in the United States. JNCI: J Natl Cancer Inst. 2024;116:1784\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVos JAM, Wieldraaijer T, van Weert H, et al. Survivorship care for cancer patients in primary versus secondary care: a systematic review. J Cancer Surviv. 2021;15:66\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026oslash;eg BL, Bidstrup PE, Karlsen RV, et al. Follow-up strategies following completion of primary cancer treatment in adult cancer survivors. Cochrane Database of Systematic Reviews; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmery JD, Jefford M, King M, et al. ProCare Trial: a phase II randomized controlled trial of shared care for follow-up of men with prostate cancer. BJU Int. 2017;119:381\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrunfeld E, Levine MN, Julian JA, et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2006;24:848\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukherjee SD, Bainbridge D, Hillis C, et al. Optimizing Cancer Survivorship Care: Examination of Factors Associated with Transition to Primary Care. Curr Oncol. 2023;30:2743\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Poth CN. Qualitative inquiry and research design: Choosing among five approaches. Sage; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiemburg GB, Korevaar JC, Logtenberg M, et al. Cancer follow-up in primary care after treatment with curative intent: Views of patients with breast and colorectal cancer. Patient Educ Couns. 2024;122:108139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStemmer SM, Steiner M, Rizel S, et al. Ten-year clinical outcomes in N0 ER+ breast cancer patients with Recurrence Score-guided therapy. NPJ Breast Cancer. 2019;5:41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNors J, Iversen LH, Erichsen R, et al. Incidence of Recurrence and Time to Recurrence in Stage I to III Colorectal Cancer: A Nationwide Danish Cohort Study. JAMA Oncol. 2024;10:54\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajaram R, Huang Q, Li RZ, et al. Recurrence-Free Survival in Patients With Surgically Resected Non-Small Cell Lung Cancer: A Systematic Literature Review and Meta-Analysis. Chest. 2024;165:1260\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrquhart R, Lethbridge L, Porter GA. Patterns of cancer centre follow-up care for survivors of breast, colorectal, gynecologic, and prostate cancer. Curr Oncol. 2017;24:360\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKendell C, Decker KM, Groome PA, et al. Use of physician services during the survivorship phase: a multi-province study of women diagnosed with breast cancer. Curr Oncol. 2017;24:81\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParmeshwar R, Margenthaler JA, Allam E, et al. Patient surveillance after initial breast cancer therapy: variation by physician specialty. Am J Surg. 2013;206:218\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis RA, Neal RD, Williams NH, et al. Follow-up of cancer in primary care versus secondary care: systematic review. Br J Gen Pract. 2009;59:e234\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSussman J, Cerasuolo JO, Pond GR, et al. 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JCO Oncol Pract. 2025;21:188\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cancer survivorship, primary care, models of care, transitions of care, survivorship care models","lastPublishedDoi":"10.21203/rs.3.rs-9255005/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9255005/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e \u003cp\u003eThere is increasing focus on transitioning cancer survivors from oncology to primary care, yet little is known about why some patients return to oncology following transition. We aimed to describe the reasons for and outcomes of subsequent oncology visits among cancer survivors transitioned to primary care.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003e We conducted a retrospective cohort study of patients transitioned to primary care at the Juravinski Cancer Centre. We analyzed all patients transitioned to primary care from 2013\u0026ndash;2020. A chart review was completed for transitioned patients with subsequent oncology visits to determine the reasons for return and subsequent investigations/treatments.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eAmong 2,604 transitioned cancer survivors, 440 (16.9%) had a subsequent oncology visit. One-third were not true rereferrals but rather visits for genetic counselling, clinical trials, or palliative care follow-up (32.7%). Apart from these, the most common reasons for visit were investigation of symptoms (32.7%) or tests (23.2%). Recurrence or new disease was detected in 28.2% of those with a subsequent visit, representing 4.8% of all transitioned patients. Most of these patients went on to receive treatment.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eOnly a small proportion of transitioned patients were referred back to oncology, and recurrence was detected in a small fraction of the overall cohort, supporting the safety of primary-care led survivorship. Patients were seen for many reasons and were readily able to reconnect with oncology regardless of underlying pathology.\u003c/p\u003e\u003ch2\u003eImplications for Cancer Survivors:\u003c/h2\u003e \u003cp\u003eTransitioning cancer survivors to primary care appears safe, with low recurrence rates and the ability to readily re-access oncology care when needed.\u003c/p\u003e","manuscriptTitle":"Subsequent Oncology Visits Among Cancer Survivors Transitioned to Primary Care: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-13 09:55:20","doi":"10.21203/rs.3.rs-9255005/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"336701572619797795575755565314130609655","date":"2026-04-07T00:02:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-04T23:35:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-30T10:31:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-30T10:31:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cancer Survivorship","date":"2026-03-28T19:43:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3ccca4b9-fff6-430d-a7b3-c23c7001a348","owner":[],"postedDate":"April 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T09:55:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-13 09:55:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9255005","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9255005","identity":"rs-9255005","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}